1770693012 NPI number — GULF SHORE DERMATOLOGY, PLLC

Table of content: (NPI 1770693012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770693012 NPI number — GULF SHORE DERMATOLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GULF SHORE DERMATOLOGY, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770693012
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1304 44TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39501-2552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-868-4006
Provider Business Mailing Address Fax Number:
228-822-2461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2112 BIENVILLE BLVD
Provider Second Line Business Practice Location Address:
SUITE F1
Provider Business Practice Location Address City Name:
OCEAN SPRINGS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39564-3052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-818-1850
Provider Business Practice Location Address Fax Number:
228-818-1807
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TORP
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
228-818-1850

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  14315 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09324843 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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